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			<h3>My Health Desire:</h3>
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					<span style="font-weight:bold">*My Goals (choose all that apply):</span>
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					<input type="checkbox" name="chkBxWeightLoss" value="weight-loss"/>Weight Loss<br/>
					<input type="checkbox" name="chkBxWeightGain" value="weight-gain"/>Weight Gain<br/>
					<input type="checkbox" name="chkBxNutrientIntake" value="nutrient-intake"/>Nutrient Intake<br/>
					<input type="checkbox" name="chkBxMaintenance" value="maintenance"/>Maintenance<br/>
					<input type="checkbox" name="chkBxGoals" value="otherGoals"/>Other - Please specify:&nbsp;
				    <input id="txtOtherGoals" type="text" />
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					<span style="font-weight:bold">*My Nutrition Quesitons:</span>
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					<input type="checkbox" name="chkBxBudget" value="budget"/>Budget<br/>
					<input type="checkbox" name="chkBxFavoriteFoods" value="favorite-foods"/>Favorite Foods<br/>
					<input type="checkbox" name="chkBxMealsSnacks" value="meals-snacks"/>Meals/Snacks per day<br/>
					<input type="checkbox" name="chkBxFoodAllergies" value="food-allergies"/>Food Allergies<br/>
					<input type="checkbox" name="chkBxEat" value="eat"/>Where you eat (work, school, home, on-the go)<br/>
					<input type="checkbox" name="chkBxNutrition" value="otherNutrition"/>Other - Please specify:&nbsp;
				    <input id="txtOtherGoals" type="text" />
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					<span style="font-weight:bold">*How would you like to receive information (Choose all that apply?):</span>
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					<input type="checkbox" name="chkBxEmail" value="email"/>Email reminders/Check ins<br/>
					<input type="checkbox" name="chkBxInfoNone" value="info-none"/>None<br/>
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					<span style="font-weight:bold">*Would you like to link your information to another online account (Choose all that apply?):</span>
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					<input type="checkbox" name="chkBxFacebook" value="facebook"/>Facebook<br/>
					<input type="checkbox" name="chkBxTwitter" value="twitter"/>Twitter<br/>
					<input type="checkbox" name="chkBxMyspace" value="myspace"/>Myspace<br/>
					<input type="checkbox" name="chkBxAccountNone" value="account-none"/>None<br/>
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            <p style="color: gray; font-size: 12px; padding-left: 8px;">Note:A text message will be sent to your phone shortly to confirm download of My Health by Design phone application.</p>
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				<button class=" awesomebtn green" title="My Health Extra Information" onclick="location.href='health-extra-information.html'">Continue &raquo;</button>		
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			<span style="color: gray; font-size: 12px;">*Required Field</span>
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